Alaska Vein Clinic Home Page Email us Home Patient Instructions Pre RFA / Venaseal Instructions Post Op RFA Instructions Post Op Venaseal Instructions Postsclerotherapy Instructions Instructions for Patient’s First Scheduled Visit About Vein Disease About Vein Disease Lymphedema May Thurner Syndrome Nocturnal Leg cramps Restless Leg Syndrome Pregnancy and Varicose Veins Vein Treatments RFA (radiofrequency ablation) Venaseal Ultrasound Guided Sclerotherapy Superficial Sclerotherapy VeinGogh Compression Stockings Contact Us AVC FORMS FOR PROVIDERS If you prefer, you may click here to print out a .pdf form and fax it. Provider Consult Referral Form Thank you for your referral. We will take good care of your patient. Provider's Information:Date: MM slash DD slash YYYY Provider's Name:* First Middle Last Degree Practice Name Practice Phone:Practice Fax:Patient Information:Communication with Patient The patient will call and make the appointment. Please call the patient to schedule the appointment. Patients Name: First Middle Last Suffix Patient Date of Birth:* MM slash DD slash YYYY AgeGender:* Female Male Patient's Contact Phone.* Is Patient a Minor? Yes No Patient's Guardian Name: First Middle Last Suffix Patient's Guardian Contact Phone.* Relationship to Patient: Mother Father Legal Guardian Alternate Phone (Optional) REASON FOR REFERRAL*Check all that apply. Varicose Veins of the Lower Extremities Varicose veins of other Sites (specify in comments) Lymphedema Leg Swelling of Uncertain Cause Deep Venous Thrombosis Superficial Thrombophlebitis Other (specify in comments) Additional Information / Comments:CommentsThis field is for validation purposes and should be left unchanged.
